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Performing a literature review

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• Gulraj S Matharu , academic foundation doctor ,
• Christopher D Buckley , Arthritis Research UK professor of rheumatology
• 1 Institute of Biomedical Research, College of Medical and Dental Sciences, School of Immunity and Infection, University of Birmingham, UK

A necessary skill for any doctor

What causes disease, which drug is best, does this patient need surgery, and what is the prognosis? Although experience helps in answering these questions, ultimately they are best answered by evidence based medicine. But how do you assess the evidence? As a medical student, and throughout your career as a doctor, critical appraisal of published literature is an important skill to develop and refine. At medical school you will repeatedly appraise published literature and write literature reviews. These activities are commonly part of a special study module, research project for an intercalated degree, or another type of essay based assignment.

Formulating a question

Literature reviews are most commonly performed to help answer a particular question. While you are at medical school, there will usually be some choice regarding the area you are going to review.

Once you have identified a subject area for review, the next step is to formulate a specific research question. This is arguably the most important step because a clear question needs to be defined from the outset, which you aim to answer by doing the review. The clearer the question, the more likely it is that the answer will be clear too. It is important to have discussions with your supervisor when formulating a research question as his or her input will be invaluable. The research question must be objective and concise because it is easier to search through the evidence with a clear question. The question also needs to be feasible. What is the point in having a question for which no published evidence exists? Your supervisor’s input will ensure you are not trying to answer an unrealistic question. Finally, is the research question clinically important? There are many research questions that may be answered, but not all of them will be relevant to clinical practice. The research question we will use as an example to work through in this article is, “What is the evidence for using angiotensin converting enzyme (ACE) inhibitors in patients with hypertension?”

Collecting the evidence

After formulating a specific research question for your literature review, the next step is to collect the evidence. Your supervisor will initially point you in the right direction by highlighting some of the more relevant papers published. Before doing the literature search it is important to agree a list of keywords with your supervisor. A source of useful keywords can be obtained by reading Cochrane reviews or other systematic reviews, such as those published in the BMJ . 1 2 A relevant Cochrane review for our research question on ACE inhibitors in hypertension is that by Heran and colleagues. 3 Appropriate keywords to search for the evidence include the words used in your research question (“angiotensin converting enzyme inhibitor,” “hypertension,” “blood pressure”), details of the types of study you are looking for (“randomised controlled trial,” “case control,” “cohort”), and the specific drugs you are interested in (that is, the various ACE inhibitors such as “ramipril,” “perindopril,” and “lisinopril”).

Once keywords have been agreed it is time to search for the evidence using the various electronic medical databases (such as PubMed, Medline, and EMBASE). PubMed is the largest of these databases and contains online information and tutorials on how to do literature searches with worked examples. Searching the databases and obtaining the articles are usually free of charge through the subscription that your university pays. Early consultation with a medical librarian is important as it will help you perform your literature search in an impartial manner, and librarians can train you to do these searches for yourself.

Literature searches can be broad or tailored to be more specific. With our example, a broad search would entail searching all articles that contain the words “blood pressure” or “ACE inhibitor.” This provides a comprehensive list of all the literature, but there are likely to be thousands of articles to review subsequently (fig 1). ⇓ In contrast, various search restrictions can be applied on the electronic databases to filter out papers that may not be relevant to your review. Figure 2 gives an example of a specific search. ⇓ The search terms used in this case were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in the English language over the last 10 years, with the search terms appearing in the title of the study only. Thus the more specific the search strategy, the more manageable the number of articles to review (fig 3), and this will save you time. ⇓ However, this method risks your not identifying all the evidence in the particular field. Striking a balance between a broad and a specific search strategy is therefore important. This will come with experience and consultation with your supervisor. It is important to note that evidence is continually becoming available on these electronic databases and therefore repeating the same search at a later date can provide new evidence relevant to your review.

Fig 1 Results from a broad literature search using the term “angiotensin converting enzyme inhibitor”

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Fig 2 Example of a specific literature search. The search terms used were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in English over the past 10 years, with the search terms appearing in the title of the study only

Fig 3 Results from a specific literature search (using the search terms and limits from figure 2)

Reading the abstracts (study summary) of the articles identified in your search may help you decide whether the study is applicable for your review—for example, the work may have been carried out using an animal model rather than in humans. After excluding any inappropriate articles, you need to obtain the full articles of studies you have identified. Additional relevant articles that may not have come up in your original search can also be found by searching the reference lists of the articles you have already obtained. Once again, you may find that some articles are still not applicable for your review, and these can also be excluded at this stage. It is important to explain in your final review what criteria you used to exclude articles as well as those criteria used for inclusion.

The National Institute for Health and Clinical Excellence (NICE) publishes evidence based guidelines for the United Kingdom and therefore provides an additional resource for identifying the relevant literature in a particular field. 4 NICE critically appraises the published literature with recommendations for best clinical practice proposed and graded based on the quality of evidence available. Similarly, there are internationally published evidence based guidelines, such as those produced by the European Society of Cardiology and the American College of Chest Physicians, which can be useful when collecting the literature in a particular field. 5 6

Appraising the evidence

Once you have collected the evidence, you need to critically appraise the published material. Box 1 gives definitions of terms you will encounter when reading the literature. A brief guide of how to critically appraise a study is presented; however, it is advisable to consult the references cited for further details.

Box 1: Definitions of common terms in the literature 7

Prospective—collecting data in real time after the study is designed

Retrospective—analysis of data that have already been collected to determine associations between exposure and outcome

Hypothesis—proposed association between exposure and outcome. If presented in the negative it is called the null hypothesis

Variable—a quantity or quality that changes during the study and can be measured

Single blind—subjects are unaware of their treatment, but clinicians are aware

Double blind—both subjects and clinicians are unaware of treatment given

Placebo—a simulated medical intervention, with subjects not receiving the specific intervention or treatment being studied

Outcome measure/endpoint—clinical variable or variables measured in a study subsequently used to make conclusions about the original interventions or treatments administered

Bias—difference between reported results and true results. Many types exist (such as selection, allocation, and reporting biases)

Probability (P) value—number between 0 and 1 providing the likelihood the reported results occurred by chance. A P value of 0.05 means there is a 5% likelihood that the reported result occurred by chance

Confidence intervals—provides a range between two numbers within which one can be certain the results lie. A confidence interval of 95% means one can be 95% certain the actual results lie within the reported range

The study authors should clearly define their research question and ideally the hypothesis to be tested. If the hypothesis is presented in the negative, it is called the null hypothesis. An example of a null hypothesis is smoking does not cause lung cancer. The study is then performed to assess the significance of the exposure (smoking) on outcome (lung cancer).

A major part of the critical appraisal process is to focus on study methodology, with your key task being an assessment of the extent to which a study was susceptible to bias (the discrepancy between the reported results and the true results). It should be clear from the methods what type of study was performed (box 2).

Box 2: Different study types 7

Systematic review/meta-analysis—comprehensive review of published literature using predefined methodology. Meta-analyses combine results from various studies to give numerical data for the overall association between variables

Randomised controlled trial—random allocation of patients to one of two or more groups. Used to test a new drug or procedure

Cohort study—two or more groups followed up over a long period, with one group exposed to a certain agent (drug or environmental agent) and the other not exposed, with various outcomes compared. An example would be following up a group of smokers and a group of non-smokers with the outcome measure being the development of lung cancer

Case-control study—cases (those with a particular outcome) are matched as closely as possible (for age, sex, ethnicity) with controls (those without the particular outcome). Retrospective data analysis is performed to determine any factors associated with developing the particular outcomes

Cross sectional study—looks at a specific group of patients at a single point in time. Effectively a survey. An example is asking a group of people how many of them drink alcohol

Case report—detailed reports concerning single patients. Useful in highlighting adverse drug reactions

There are many different types of bias, which depend on the particular type of study performed, and it is important to look for these biases. Several published checklists are available that provide excellent resources to help you work through the various studies and identify sources of bias. The CONSORT statement (which stands for CONsolidated Standards Of Reporting Trials) provides a minimum set of recommendations for reporting randomised controlled trials and comprises a rigorous 25 item checklist, with variations available for other study types. 8 9 As would be expected, most (17 of 25) of the items focus on questions relating to the methods and results of the randomised trial. The remaining items relate to the title, abstract, introduction, and discussion of the study, in addition to questions on trial registration, protocol, and funding.

Jadad scoring provides a simple and validated system to assess the methodological quality of a randomised clinical trial using three questions. 10 The score ranges from zero to five, with one point given for a “yes” in each of the following questions. (1) Was the study described as randomised? (2) Was the study described as double blind? (3) Were there details of subject withdrawals, exclusions, and dropouts? A further point is given if (1) the method of randomisation was appropriate, and (2) the method of blinding was appropriate.

In addition, the Critical Appraisal Skills Programme provides excellent tools for assessing the evidence in all study types (box 2). 11 The Oxford Centre for Evidence-Based Medicine levels of evidence is yet another useful resource for assessing the methodological quality of all studies. 12

Ensure all patients have been accounted for and any exclusions, for whatever reason, are reported. Knowing the baseline demographic (age, sex, ethnicity) and clinical characteristics of the population is important. Results are usually reported as probability values or confidence intervals (box 1).

This should explain the major study findings, put the results in the context of the published literature, and attempt to account for any variations from previous work. Study limitations and sources of bias should be discussed. Authors’ conclusions should be supported by the study results and not unnecessarily extrapolated. For example, a treatment shown to be effective in animals does not necessarily mean it will work in humans.

The format for writing up the literature review usually consists of an abstract (short structured summary of the review), the introduction or background, methods, results, and discussion with conclusions. There are a number of good examples of how to structure a literature review and these can be used as an outline when writing your review. 13 14

The introduction should identify the specific research question you intend to address and briefly put this into the context of the published literature. As you have now probably realised, the methods used for the review must be clear to the reader and provide the necessary detail for someone to be able to reproduce the search. The search strategy needs to include a list of keywords used, which databases were searched, and the specific search limits or filters applied. Any grading of methodological quality, such as the CONSORT statement or Jadad scoring, must be explained in addition to any study inclusion or exclusion criteria. 6 7 8 The methods also need to include a section on the data collected from each of the studies, the specific outcomes of interest, and any statistical analysis used. The latter point is usually relevant only when performing meta-analyses.

The results section must clearly show the process of filtering down from the articles obtained from the original search to the final studies included in the review—that is, accounting for all excluded studies. A flowchart is usually best to illustrate this. Next should follow a brief description of what was done in the main studies, the number of participants, the relevant results, and any potential sources of bias. It is useful to group similar studies together as it allows comparisons to be made by the reader and saves repetition in your write-up. Boxes and figures should be used appropriately to illustrate important findings from the various studies.

Finally, in the discussion you need to consider the study findings in light of the methodological quality—that is, the extent of potential bias in each study that may have affected the study results. Using the evidence, you need to make conclusions in your review, and highlight any important gaps in the evidence base, which need to be dealt with in future studies. Working through drafts of the literature review with your supervisor will help refine your critical appraisal skills and the ability to present information concisely in a structured review article. Remember, if the work is good it may get published.

Originally published as: Student BMJ 2012;20:e404

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

• ↵ The Cochrane Library. www3.interscience.wiley.com/cgibin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0 .
• ↵ British Medical Journal . www.bmj.com/ .
• ↵ Heran BS, Wong MMY, Heran IK, Wright JM. Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension. Cochrane Database Syst Rev 2008 ; 4 : CD003823 , doi: 10.1002/14651858.CD003823.pub2. OpenUrl PubMed
• ↵ National Institute for Health and Clinical Excellence. www.nice.org.uk .
• ↵ European Society of Cardiology. www.escardio.org/guidelines .
• ↵ Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed). Chest 2008 ; 133 : 381 -453S. OpenUrl CrossRef
• ↵ Wikipedia. http://en.wikipedia.org/wiki .
• ↵ Moher D, Schulz KF, Altman DG, Egger M, Davidoff F, Elbourne D, et al. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001 ; 357 : 1191 -4. OpenUrl CrossRef PubMed Web of Science
• ↵ The CONSORT statement. www.consort-statement.org/ .
• ↵ Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996 ; 17 : 1 -12. OpenUrl CrossRef PubMed Web of Science
• ↵ Critical Appraisal Skills Programme (CASP). www.sph.nhs.uk/what-we-do/public-health-workforce/resources/critical-appraisals-skills-programme .
• ↵ Oxford Centre for Evidence-based Medicine—Levels of Evidence. www.cebm.net .
• ↵ Van den Bruel A, Thompson MJ, Haj-Hassan T, Stevens R, Moll H, Lakhanpaul M, et al . Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ 2011 ; 342 : d3082 . OpenUrl Abstract / FREE Full Text
• ↵ Awopetu AI, Moxey P, Hinchliffe RJ, Jones KG, Thompson MM, Holt PJ. Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery. Br J Surg 2010 ; 97 : 797 -803. OpenUrl CrossRef PubMed

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What is a literature review?

Systematic reviews vs literature reviews, literature reviews - articles, writing literature reviews, frequently used journal article databases.

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The literature review is the qualitative summary of evidence on a topic using informal or subjective methods to collect and interpret studies.The literature review can inform a particular research project or can result in a review article publication.

• Aaron L. Writing a literature review article. Radiol Technol. 2008 Nov-Dec; 80(12): 185-6.
• Gasparyan AY, Ayvazyan L, Blackmore H, Kitas GD. Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors. Rheumatol Int. 2011 Nov; 31(11): 1409-17.
• Matharu GS, Buckley CD. Performing a literature review: a necessary skill for any doctor. Student BMJ. 2012; 20:e404. Requires FREE site registration
• Literature Reviews The Writing Center at University of North Carolina at Chapel Hill has created a succinct handout that explains what a literature review is and offer insights into the form and construction of a literature review in the humanities, social sciences, and sciences.
• Review Articles (Health Sciences) Guide Identifies the difference between a systematic review and a literature review. Connects to tools for research, writing, and publishing.

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• The Pandora's Box of Evidence Synthesis and the case for a living Evidence Synthesis Taxonomy | BMJ Evidence-Based Medicine, 2023
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• Ten simple rules for writing a literature review | PLoS Computational Biology, 2013
• The Purpose, Process, and Methods of Writing a Literature Review | AORN Journal. 2016
• Why, When, Who, What, How, and Where for Trainees Writing Literature Review Articles. | Annals of Biomed Engineering, 2019
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• The Literature Review: A Foundation for High-Quality Medical Education Research | Journal of Graduate Medical Education, 2016
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Home » Office of Curriculum » Medical Student Scholarship » III Scholarship Start Here » Scholarship of Integration » Key Steps in a Literature Review

Key Steps in a Literature Review

The 5 key steps  below are most relevant to narrative reviews. Systematic reviews include the additional step of using a standardized scoring system to assess the quality of each article. More information on  Step 1 can be found  here  and Step 5  here .

• Consider the purpose and rationale of a review
• Clearly articulate the components of the question
• The research question and purpose of your review should guide the development of your search strategy (i.e. which databases to search and which search terms to use)
• Justify any limitations you create for your search,
• Determine inclusion and exclusion criteria.
• Start by reviewing abstracts for relevant articles. Once this is complete, then begin a full text review of the remaining articles.
• Develop a data-charting form to extract data from each article. Update this form as needed if you find there is more information worth collecting.
• The resulting forms will serve as a summary of each article that will facilitate the process of synthesizing your results (i.e. the selected articles).
• In your analysis, include a numerical summary of studies included, an evidence table summarizing included articles, and a qualitative summary of the results.
• Report the results in the context of the overall purpose or research question.
• Consider the meaning of your results. Discuss limitations and implications for future research, practice, and/or policy.

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The use of drugs and medical students: a literature review

Affiliations.

• 1 4Th-year Medical Students fo the State University of Ponta Grossa (PR), Brazil.
• 2 Master in Science and Technology Teaching; Associate Professor of the Medical Program of the State University of Ponta Grossa (PR), Brazil.
• 3 PhD in Internal Medicine; Adjunct Professor of Medicine at the Ponta Grossa State University (UEPG), Ponta Grossa (PR), Brazil.
• PMID: 30304147
• DOI: 10.1590/1806-9282.64.05.462

Introduction: The consumption and abuse of alcohol and other drugs are increasingly present in the lives of university students and may already be considered a public health problem because of the direct impacts on the physical and mental health of these individuals. The requirements of the medical program play a vital role in the increasing rate of drug users.

Objectives: To carry out a systematic review of the literature on the use of drugs, licit or not, in Brazilian medical students.

Methods: A descriptive-exploratory study, in which the SciELO and MEDLINE databases were used. A total of 99 articles were found, of which 16 were selected for this review.

Results: Alcohol and tobacco were the most frequently used licit drugs among medical students. The most consumed illicit drugs were marijuana, solvents, "lança-perfume" (ether spray), and anxiolytics. The male genre presented a tendency of consuming more significant amounts of all kinds of drugs, with the exception of tranquilizers. It was found an increasing prevalence of drug consumption in medical students, as the program progressed, which may result from the intrinsic stress from medical school activities. Students who do not use psychoactive drugs are more likely to live with their parents, to disapprove drugs consumption, to practice religious beliefs and to be employed.

Conclusion: The prevalence of licit and illicit drug use among medical students is high, even though they understand the injuries it may cause.

Publication types

• Systematic Review
• Alcohol Drinking / epidemiology
• Brazil / epidemiology
• Illicit Drugs
• Marijuana Smoking / epidemiology
• Sex Factors
• Smoking / epidemiology
• Students, Medical / psychology*
• Substance-Related Disorders / epidemiology*

• Open access
• Published: 23 April 2024

Designing feedback processes in the workplace-based learning of undergraduate health professions education: a scoping review

• Javiera Fuentes-Cimma 1 , 2 ,
• Dominique Sluijsmans 3 ,
• Arnoldo Riquelme 4 ,
• Ignacio Villagran   ORCID: orcid.org/0000-0003-3130-8326 1 ,
• Lorena Isbej   ORCID: orcid.org/0000-0002-4272-8484 2 , 5 ,
• María Teresa Olivares-Labbe 6 &
• Sylvia Heeneman 7  

BMC Medical Education volume  24 , Article number:  440 ( 2024 ) Cite this article

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Metrics details

Feedback processes are crucial for learning, guiding improvement, and enhancing performance. In workplace-based learning settings, diverse teaching and assessment activities are advocated to be designed and implemented, generating feedback that students use, with proper guidance, to close the gap between current and desired performance levels. Since productive feedback processes rely on observed information regarding a student's performance, it is imperative to establish structured feedback activities within undergraduate workplace-based learning settings. However, these settings are characterized by their unpredictable nature, which can either promote learning or present challenges in offering structured learning opportunities for students. This scoping review maps literature on how feedback processes are organised in undergraduate clinical workplace-based learning settings, providing insight into the design and use of feedback.

A scoping review was conducted. Studies were identified from seven databases and ten relevant journals in medical education. The screening process was performed independently in duplicate with the support of the StArt program. Data were organized in a data chart and analyzed using thematic analysis. The feedback loop with a sociocultural perspective was used as a theoretical framework.

The search yielded 4,877 papers, and 61 were included in the review. Two themes were identified in the qualitative analysis: (1) The organization of the feedback processes in workplace-based learning settings, and (2) Sociocultural factors influencing the organization of feedback processes. The literature describes multiple teaching and assessment activities that generate feedback information. Most papers described experiences and perceptions of diverse teaching and assessment feedback activities. Few studies described how feedback processes improve performance. Sociocultural factors such as establishing a feedback culture, enabling stable and trustworthy relationships, and enhancing student feedback agency are crucial for productive feedback processes.

Conclusions

This review identified concrete ideas regarding how feedback could be organized within the clinical workplace to promote feedback processes. The feedback encounter should be organized to allow follow-up of the feedback, i.e., working on required learning and performance goals at the next occasion. The educational programs should design feedback processes by appropriately planning subsequent tasks and activities. More insight is needed in designing a full-loop feedback process, in which specific attention is needed in effective feedforward practices.

Peer Review reports

The design of effective feedback processes in higher education has been important for educators and researchers and has prompted numerous publications discussing potential mechanisms, theoretical frameworks, and best practice examples over the past few decades. Initially, research on feedback primarily focused more on teachers and feedback delivery, and students were depicted as passive feedback recipients [ 1 , 2 , 3 ]. The feedback conversation has recently evolved to a more dynamic emphasis on interaction, sense-making, outcomes in actions, and engagement with learners [ 2 ]. This shift aligns with utilizing the feedback process as a form of social interaction or dialogue to enhance performance [ 4 ]. Henderson et al. (2019) defined feedback processes as "where the learner makes sense of performance-relevant information to promote their learning." (p. 17). When a student grasps the information concerning their performance in connection to the desired learning outcome and subsequently takes suitable action, a feedback loop is closed so the process can be regarded as successful [ 5 , 6 ].

Hattie and Timperley (2007) proposed a comprehensive perspective on feedback, the so-called feedback loop, to answer three key questions: “Where am I going? “How am I going?” and “Where to next?” [ 7 ]. Each question represents a key dimension of the feedback loop. The first is the feed-up, which consists of setting learning goals and sharing clear objectives of learners' performance expectations. While the concept of the feed-up might not be consistently included in the literature, it is considered to be related to principles of effective feedback and goal setting within educational contexts [ 7 , 8 ]. Goal setting allows students to focus on tasks and learning, and teachers to have clear intended learning outcomes to enable the design of aligned activities and tasks in which feedback processes can be embedded [ 9 ]. Teachers can improve the feed-up dimension by proposing clear, challenging, but achievable goals [ 7 ]. The second dimension of the feedback loop focuses on feedback and aims to answer the second question by obtaining information about students' current performance. Different teaching and assessment activities can be used to obtain feedback information, and it can be provided by a teacher or tutor, a peer, oneself, a patient, or another coworker. The last dimension of the feedback loop is the feedforward, which is specifically associated with using feedback to improve performance or change behaviors [ 10 ]. Feedforward is crucial in closing the loop because it refers to those specific actions students must take to reduce the gap between current and desired performance [ 7 ].

From a sociocultural perspective, feedback processes involve a social practice consisting of intricate relationships within a learning context [ 11 ]. The main feature of this approach is that students learn from feedback only when the feedback encounter includes generating, making sense of, and acting upon the information given [ 11 ]. In the context of workplace-based learning (WBL), actionable feedback plays a crucial role in enabling learners to leverage specific feedback to enhance their performance, skills, and conceptual understandings. The WBL environment provides students with a valuable opportunity to gain hands-on experience in authentic clinical settings, in which students work more independently on real-world tasks, allowing them to develop and exhibit their competencies [ 3 ]. However, WBL settings are characterized by their unpredictable nature, which can either promote self-directed learning or present challenges in offering structured learning opportunities for students [ 12 ]. Consequently, designing purposive feedback opportunities within WBL settings is a significant challenge for clinical teachers and faculty.

In undergraduate clinical education, feedback opportunities are often constrained due to the emphasis on clinical work and the absence of dedicated time for teaching [ 13 ]. Students are expected to perform autonomously under supervision, ideally achieved by giving them space to practice progressively and providing continuous instances of constructive feedback [ 14 ]. However, the hierarchy often present in clinical settings places undergraduate students in a dependent position, below residents and specialists [ 15 ]. Undergraduate or junior students may have different approaches to receiving and using feedback. If their priority is meeting the minimum standards given pass-fail consequences and acting merely as feedback recipients, other incentives may be needed to engage with the feedback processes because they will need more learning support [ 16 , 17 ]. Adequate supervision and feedback have been recognized as vital educational support in encouraging students to adopt a constructive learning approach [ 18 ]. Given that productive feedback processes rely on observed information regarding a student's performance, it is imperative to establish structured teaching and learning feedback activities within undergraduate WBL settings.

Despite the extensive research on feedback, a significant proportion of published studies involve residents or postgraduate students [ 19 , 20 ]. Recent reviews focusing on feedback interventions within medical education have clearly distinguished between undergraduate medical students and residents or fellows [ 21 ]. To gain a comprehensive understanding of initiatives related to actionable feedback in the WBL environment for undergraduate health professions, a scoping review of the existing literature could provide insight into how feedback processes are designed in that context. Accordingly, the present scoping review aims to answer the following research question: How are the feedback processes designed in the undergraduate health professions' workplace-based learning environments?

A scoping review was conducted using the five-step methodological framework proposed by Arksey and O'Malley (2005) [ 22 ], intertwined with the PRISMA checklist extension for scoping reviews to provide reporting guidance for this specific type of knowledge synthesis [ 23 ]. Scoping reviews allow us to study the literature without restricting the methodological quality of the studies found, systematically and comprehensively map the literature, and identify gaps [ 24 ]. Furthermore, a scoping review was used because this topic is not suitable for a systematic review due to the varied approaches described and the large difference in the methodologies used [ 21 ].

Search strategy

With the collaboration of a medical librarian, the authors used the research question to guide the search strategy. An initial meeting was held to define keywords and search resources. The proposed search strategy was reviewed by the research team, and then the study selection was conducted in two steps:

An online database search included Medline/PubMed, Web of Science, CINAHL, Cochrane Library, Embase, ERIC, and PsycINFO.

A directed search of ten relevant journals in the health sciences education field (Academic Medicine, Medical Education, Advances in Health Sciences Education, Medical Teacher, Teaching and Learning in Medicine, Journal of Surgical Education, BMC Medical Education, Medical Education Online, Perspectives on Medical Education and The Clinical Teacher) was performed.

The research team conducted a pilot or initial search before the full search to identify if the topic was susceptible to a scoping review. The full search was conducted in November 2022. One team member (MO) identified the papers in the databases. JF searched in the selected journals. Authors included studies written in English due to feasibility issues, with no time span limitation. After eliminating duplicates, two research team members (JF and IV) independently reviewed all the titles and abstracts using the exclusion and inclusion criteria described in Table  2 and with the support of the screening application StArT [ 25 ]. A third team member (AR) reviewed the titles and abstracts when the first two disagreed. The reviewer team met again at a midpoint and final stage to discuss the challenges related to study selection. Articles included for full-text review were exported to Mendeley. JF independently screened all full-text papers, and AR verified 10% for inclusion. The authors did not analyze study quality or risk of bias during study selection, which is consistent with conducting a scoping review.

The analysis of the results incorporated a descriptive summary and a thematic analysis, which was carried out to clarify and give consistency to the results' reporting [ 22 , 24 , 26 ]. Quantitative data were analyzed to report the characteristics of the studies, populations, settings, methods, and outcomes. Qualitative data were labeled, coded, and categorized into themes by three team members (JF, SH, and DS). The feedback loop framework with a sociocultural perspective was used as the theoretical framework to analyze the results.

The keywords used for the search strategies were as follows:

Clinical clerkship; feedback; formative feedback; health professions; undergraduate medical education; workplace.

Definitions of the keywords used for the present review are available in Appendix 1 .

As an example, we included the search strategy that we used in the Medline/PubMed database when conducting the full search:

("Formative Feedback"[Mesh] OR feedback) AND ("Workplace"[Mesh] OR workplace OR "Clinical Clerkship"[Mesh] OR clerkship) AND (("Education, Medical, Undergraduate"[Mesh] OR undergraduate health profession*) OR (learner* medical education)).

Inclusion and exclusion criteria

The following inclusion and exclusion criteria were used (Table  1 ):

Data extraction

The research group developed a data-charting form to organize the information obtained from the studies. The process was iterative, as the data chart was continuously reviewed and improved as necessary. In addition, following Levac et al.'s recommendation (2010), the three members involved in the charting process (JF, LI, and IV) independently reviewed the first five selected studies to determine whether the data extraction was consistent with the objectives of this scoping review and to ensure consistency. Then, the team met using web-conferencing software (Zoom; CA, USA) to review the results and adjust any details in the chart. The same three members extracted data independently from all the selected studies, considering two members reviewing each paper [ 26 ]. A third team member was consulted if any conflict occurred when extracting data. The data chart identified demographic patterns and facilitated the data synthesis. To organize data, we used a shared Excel spreadsheet, considering the following headings: title, author(s), year of publication, journal/source, country/origin, aim of the study, research question (if any), population/sample size, participants, discipline, setting, methodology, study design, data collection, data analysis, intervention, outcomes, outcomes measure, key findings, and relation of findings to research question.

Additionally, all the included papers were uploaded to AtlasTi v19 to facilitate the qualitative analysis. Three team members (JF, SH, and DS) independently coded the first six papers to create a list of codes to ensure consistency and rigor. The group met several times to discuss and refine the list of codes. Then, one member of the team (JF) used the code list to code all the rest of the papers. Once all papers were coded, the team organized codes into descriptive themes aligned with the research question.

Preliminary results were shared with a number of stakeholders (six clinical teachers, ten students, six medical educators) to elicit their opinions as an opportunity to build on the evidence and offer a greater level of meaning, content expertise, and perspective to the preliminary findings [ 26 ]. No quality appraisal of the studies is considered for this scoping review, which aligns with the frameworks for guiding scoping reviews [ 27 ].

The datasets analyzed during the current study are available from the corresponding author upon request.

A database search resulted in 3,597 papers, and the directed search of the most relevant journals in the health sciences education field yielded 2,096 titles. An example of the results of one database is available in Appendix 2 . Of the titles obtained, 816 duplicates were eliminated, and the team reviewed the titles and abstracts of 4,877 papers. Of these, 120 were selected for full-text review. Finally, 61 papers were included in this scoping review (Fig.  1 ), as listed in Table  2 .

PRISMA flow diagram for included studies, incorporating records identified through the database and direct searching

The selected studies were published between 1986 and 2022, and seventy-five percent (46) were published during the last decade. Of all the articles included in this review, 13% (8) were literature reviews: one integrative review [ 28 ] and four scoping reviews [ 29 , 30 , 31 , 32 ]. Finally, fifty-three (87%) original or empirical papers were included (i.e., studies that answered a research question or achieved a research purpose through qualitative or quantitative methodologies) [ 15 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 ].

Table 2 summarizes the papers included in the present scoping review, and Table  3 describes the characteristics of the included studies.

The thematic analysis resulted in two themes: (1) the organization of feedback processes in WBL settings, and (2) sociocultural factors influencing the organization of feedback processes. Table 4 gives a summary of the themes and subthemes.

Organization of feedback processes in WBL settings.

Setting learning goals (i.e., feed-up dimension).

Feedback that focuses on students' learning needs and is based on known performance standards enhances student response and setting learning goals [ 30 ]. Discussing goals and agreements before starting clinical practice enhances students' feedback-seeking behavior [ 39 ] and responsiveness to feedback [ 83 ]. Farrell et al. (2017) found that teacher-learner co-constructed learning goals enhance feedback interactions and help establish educational alliances, improving the learning experience [ 50 ]. However, Kiger (2020) found that sharing individualized learning plans with teachers aligned feedback with learning goals but did not improve students' perceived use of feedback [ 64 ]

Two papers of this set pointed out the importance of goal-oriented feedback, a dynamic process that depends on discussion of goal setting between teachers and students [ 50 ] and influences how individuals experience, approach, and respond to upcoming learning activities [ 34 ]. Goal-oriented feedback should be embedded in the learning experience of the clinical workplace, as it can enhance students' engagement in safe feedback dialogues [ 50 ]. Ideally, each feedback encounter in the WBL context should conclude, in addition to setting a plan of action to achieve the desired goal, with a reflection on the next goal [ 50 ].

Feedback strategies within the WBL environment. (i.e., feedback dimension)

In undergraduate WBL environments, there are several tasks and feedback opportunities organized in the undergraduate clinical workplace that can enable feedback processes:

Questions from clinical teachers to students are a feedback strategy [ 74 ]. There are different types of questions that the teacher can use, either to clarify concepts, to reach the correct answer, or to facilitate self-correction [ 74 ]. Usually, questions can be used in conjunction with other communication strategies, such as pauses, which enable self-correction by the student [ 74 ]. Students can also ask questions to obtain feedback on their performance [ 54 ]. However, question-and-answer as a feedback strategy usually provides information on either correct or incorrect answers and fewer suggestions for improvement, rendering it less constructive as a feedback strategy [ 82 ].

Direct observation of performance by default is needed to be able to provide information to be used as input in the feedback process [ 33 , 46 , 49 , 86 ]. In the process of observation, teachers can include clarification of objectives (i.e., feed-up dimension) and suggestions for an action plan (i.e., feedforward) [ 50 ]. Accordingly, Schopper et al. (2016) showed that students valued being observed while interviewing patients, as they received feedback that helped them become more efficient and effective as interviewers and communicators [ 33 ]. Moreover, it is widely described that direct observation improves feedback credibility [ 33 , 40 , 84 ]. Ideally, observation should be deliberate [ 33 , 83 ], informal or spontaneous [ 33 ], conducted by a (clinical) expert [ 46 , 86 ], provided immediately after the observation, and clinical teacher if possible, should schedule or be alert on follow-up observations to promote closing the gap between current and desired performance [ 46 ].

Workplace-based assessments (WBAs), by definition, entail direct observation of performance during authentic task demonstration [ 39 , 46 , 56 , 87 ]. WBAs can significantly impact behavioral change in medical students [ 55 ]. Organizing and designing formative WBAs and embedding these in a feedback dialogue is essential for effective learning [ 31 ].

Summative organization of WBAs is a well described barrier for feedback uptake in the clinical workplace [ 35 , 46 ]. If feedback is perceived as summative, or organized as a pass-fail decision, students may be less inclined to use the feedback for future learning [ 52 ]. According to Schopper et al. (2016), using a scale within a WBA makes students shift their focus during the clinical interaction and see it as an assessment with consequences [ 33 ]. Harrison et al. (2016) pointed out that an environment that only contains assessments with a summative purpose will not lead to a culture of learning and improving performance [ 56 ]. The recommendation is to separate the formative and summative WBAs, as feedback in summative instances is often not recognized as a learning opportunity or an instance to seek feedback [ 54 ]. In terms of the design, an organizational format is needed to clarify to students how formative assessments can promote learning from feedback [ 56 ]. Harrison et al. (2016) identified that enabling students to have more control over their assessments, designing authentic assessments, and facilitating long-term mentoring could improve receptivity to formative assessment feedback [ 56 ].

Multiple WBA instruments and systems are reported in the literature. Sox et al. (2014) used a detailed evaluation form to help students improve their clinical case presentation skills. They found that feedback on oral presentations provided by supervisors using a detailed evaluation form improved clerkship students’ oral presentation skills [ 78 ]. Daelmans et al. (2006) suggested that a formal in-training assessment programme composed by 19 assessments that provided structured feedback, could promote observation and verbal feedback opportunities through frequent assessments [ 43 ]. However, in this setting, limited student-staff interactions still hindered feedback follow-up [ 43 ]. Designing frequent WBA improves feedback credibility [ 28 ]. Long et al. (2021) emphasized that students' responsiveness to assessment feedback hinges on its perceived credibility, underlining the importance of credibility for students to effectively engage and improve their performance [ 31 ].

The mini-CEX is one of the most widely described WBA instruments in the literature. Students perceive that the mini-CEX allows them to be observed and encourages the development of interviewing skills [ 33 ]. The mini-CEX can provide feedback that improves students' clinical skills [ 58 , 60 ], as it incorporates a structure for discussing the student's strengths and weaknesses and the design of a written action plan [ 39 , 80 ]. When mini-CEXs are incorporated as part of a system of WBA, such as programmatic assessment, students feel confident in seeking feedback after observation, and being systematic allows for follow-up [ 39 ]. Students suggested separating grading from observation and using the mini-CEX in more informal situations [ 33 ].

Clinical encounter cards allow students to receive weekly feedback and make them request more feedback as the clerkship progresses [ 65 ]. Moreover, encounter cards stimulate that feedback is given by supervisors, and students are more satisfied with the feedback process [ 72 ]. With encounter card feedback, students are responsible for asking a supervisor for feedback before a clinical encounter, and supervisors give students written and verbal comments about their performance after the encounter [ 42 , 72 ]. Encounter cards enhance the use of feedback and add approximately one minute to the length of the clinical encounter, so they are well accepted by students and supervisors [ 72 ]. Bennett (2006) identified that Instant Feedback Cards (IFC) facilitated mid-rotation feedback [ 38 ]. Feedback encounter card comments must be discussed between students and supervisors; otherwise, students may perceive it as impersonal, static, formulaic, and incomplete [ 59 ].

Self-assessments can change students' feedback orientation, transforming them into coproducers of learning [ 68 ]. Self-assessments promote the feedback process [ 68 ]. Some articles emphasize the importance of organizing self-assessments before receiving feedback from supervisors, for example, discussing their appraisal with the supervisor [ 46 , 52 ]. In designing a feedback encounter, starting with a self-assessment as feed-up, discussing with the supervisor, and identifying areas for improvement is recommended, as part of the feedback dialogue [ 68 ].

Peer feedback as an organized activity allows students to develop strategies to observe and give feedback to other peers [ 61 ]. Students can act as the feedback provider or receiver, fostering understanding of critical comments and promoting evaluative judgment for their clinical practice [ 61 ]. Within clerkships, enabling the sharing of feedback information among peers allows for a better understanding and acceptance of feedback [ 52 ]. However, students can find it challenging to take on the peer assessor/feedback provider role, as they prefer to avoid social conflicts [ 28 , 61 ]. Moreover, it has been described that they do not trust the judgment of their peers because they are not experts, although they know the procedures, tasks, and steps well and empathize with their peer status in the learning process [ 61 ].

Bedside-teaching encounters (BTEs) provide timely feedback and are an opportunity for verbal feedback during performance [ 74 ]. Rizan et al. (2014) explored timely feedback delivered within BTEs and determined that it promotes interaction that constructively enhances learner development through various corrective strategies (e.g., question and answers, pauses, etc.). However, if the feedback given during the BTEs was general, unspecific, or open-ended, it could go unnoticed [ 74 ]. Torre et al. (2005) investigated which integrated feedback activities and clinical tasks occurred on clerkship rotations and assessed students' perceived quality in each teaching encounter [ 81 ]. The feedback activities reported were feedback on written clinical history, physical examination, differential diagnosis, oral case presentation, a daily progress note, and bedside feedback. Students considered all these feedback activities high-quality learning opportunities, but they were more likely to receive feedback when teaching was at the bedside than at other teaching locations [ 81 ].

Case presentations are an opportunity for feedback within WBL contexts [ 67 , 73 ]. However, both students and supervisors struggled to identify them as feedback moments, and they often dismissed questions and clarifications around case presentations as feedback [ 73 ]. Joshi (2017) identified case presentations as a way for students to ask for informal or spontaneous supervisor feedback [ 63 ].

Organization of follow-up feedback and action plans (i.e., feedforward dimension).

Feedback that generates use and response from students is characterized by two-way communication and embedded in a dialogue [ 30 ]. Feedback must be future-focused [ 29 ], and a feedback encounter should be followed by planning the next observation [ 46 , 87 ]. Follow-up feedback could be organized as a future self-assessment, reflective practice by the student, and/or a discussion with the supervisor or coach [ 68 ]. The literature describes that a lack of student interaction with teachers makes follow-up difficult [ 43 ]. According to Haffling et al. (2011), follow-up feedback sessions improve students' satisfaction with feedback compared to students who do not have follow-up sessions. In addition, these same authors reported that a second follow-up session allows verification of improved performances or confirmation that the skill was acquired [ 55 ].

Although feedback encounter forms are a recognized way of obtaining information about performance (i.e., feedback dimension), the literature does not provide many clear examples of how they may impact the feedforward phase. For example, Joshi et al. (2016) consider a feedback form with four fields (i.e., what did you do well, advise the student on what could be done to improve performance, indicate the level of proficiency, and personal details of the tutor). In this case, the supervisor highlighted what the student could improve but not how, which is the missing phase of the co-constructed action plan [ 63 ]. Whichever WBA instrument is used in clerkships to provide feedback, it should include a "next steps" box [ 44 ], and it is recommended to organize a long-term use of the WBA instrument so that those involved get used to it and improve interaction and feedback uptake [ 55 ]. RIME-based feedback (Reporting, Interpreting, Managing, Educating) is considered an interesting example, as it is perceived as helpful to students in knowing what they need to improve in their performance [ 44 ]. Hochberg (2017) implemented formative mid-clerkship assessments to enhance face-to-face feedback conversations and co-create an improvement plan [ 59 ]. Apps for structuring and storing feedback improve the amount of verbal and written feedback. In the study of Joshi et al. (2016), a reasonable proportion of students (64%) perceived that these app tools help them improve their performance during rotations [ 63 ].

Several studies indicate that an action plan as part of the follow-up feedback is essential for performance improvement and learning [ 46 , 55 , 60 ]. An action plan corresponds to an agreed-upon strategy for improving, confirming, or correcting performance. Bing-You et al. (2017) determined that only 12% of the articles included in their scoping review incorporated an action plan for learners [ 32 ]. Holmboe et al. (2004) reported that only 11% of the feedback sessions following a mini-CEX included an action plan [ 60 ]. Suhoyo et al. (2017) also reported that only 55% of mini-CEX encounters contained an action plan [ 80 ]. Other authors reported that action plans are not commonly offered during feedback encounters [ 77 ]. Sokol-Hessner et al. (2010) implemented feedback card comments with a space to provide written feedback and a specific action plan. In their results, 96% contained positive comments, and only 5% contained constructive comments [ 77 ]. In summary, although the recommendation is to include a “next step” box in the feedback instruments, evidence shows these items are not often used for constructive comments or action plans.

Sociocultural factors influencing the organization of feedback processes.

Multiple sociocultural factors influence interaction in feedback encounters, promoting or hampering the productivity of the feedback processes.

Clinical learning culture

Context impacts feedback processes [ 30 , 82 ], and there are barriers to incorporating actionable feedback in the clinical learning context. The clinical learning culture is partly determined by the clinical context, which can be unpredictable [ 29 , 46 , 68 ], as the available patients determine learning opportunities. Supervisors are occupied by a high workload, which results in limited time or priority for teaching [ 35 , 46 , 48 , 55 , 68 , 83 ], hindering students’ feedback-seeking behavior [ 54 ], and creating a challenge for the balance between patient care and student mentoring [ 35 ].

Clinical workplace culture does not always purposefully prioritize instances for feedback processes [ 83 , 84 ]. This often leads to limited direct observation [ 55 , 68 ] and the provision of poorly informed feedback. It is also evident that this affects trust between clinical teachers and students [ 52 ]. Supervisors consider feedback a low priority in clinical contexts [ 35 ] due to low compensation and lack of protected time [ 83 ]. In particular, lack of time appears to be the most significant and well-known barrier to frequent observation and workplace feedback [ 35 , 43 , 48 , 62 , 67 , 83 ].

The clinical environment is hierarchical [ 68 , 80 ] and can make students not consider themselves part of the team and feel like a burden to their supervisor [ 68 ]. This hierarchical learning environment can lead to unidirectional feedback, limit dialogue during feedback processes, and hinder the seeking, uptake, and use of feedback [ 67 , 68 ]. In a learning culture where feedback is not supported, learners are less likely to want to seek it and feel motivated and engaged in their learning [ 83 ]. Furthermore, it has been identified that clinical supervisors lack the motivation to teach [ 48 ] and the intention to observe or reobserve performance [ 86 ].

In summary, the clinical context and WBL culture do not fully use the potential of a feedback process aimed at closing learning gaps. However, concrete actions shown in the literature can be taken to improve the effectiveness of feedback by organizing the learning context. For example, McGinness et al. (2022) identified that students felt more receptive to feedback when working in a safe, nonjudgmental environment [ 67 ]. Moreover, supervisors and trainees identified the learning culture as key to establishing an open feedback dialogue [ 73 ]. Students who perceive culture as supportive and formative can feel more comfortable performing tasks and more willing to receive feedback [ 73 ].

Relationships

There is a consensus in the literature that trusting and long-term relationships improve the chances of actionable feedback. However, relationships between supervisors and students in the clinical workplace are often brief and not organized as more longitudinally [ 68 , 83 ], leaving little time to establish a trustful relationship [ 68 ]. Supervisors change continuously, resulting in short interactions that limit the creation of lasting relationships over time [ 50 , 68 , 83 ]. In some contexts, it is common for a student to have several supervisors who have their own standards in the observation of performance [ 46 , 56 , 68 , 83 ]. A lack of stable relationships results in students having little engagement in feedback [ 68 ]. Furthermore, in case of summative assessment programmes, the dual role of supervisors (i.e., assessing and giving feedback) makes feedback interactions perceived as summative and can complicate the relationship [ 83 ].

Repeatedly, the articles considered in this review describe that long-term and stable relationships enable the development of trust and respect [ 35 , 62 ] and foster feedback-seeking behavior [ 35 , 67 ] and feedback-giver behavior [ 39 ]. Moreover, constructive and positive relationships enhance students´ use of and response to feedback [ 30 ]. For example, Longitudinal Integrated Clerkships (LICs) promote stable relationships, thus enhancing the impact of feedback [ 83 ]. In a long-term trusting relationship, feedback can be straightforward and credible [ 87 ], there are more opportunities for student observation, and the likelihood of follow-up and actionable feedback improves [ 83 ]. Johnson et al. (2020) pointed out that within a clinical teacher-student relationship, the focus must be on establishing psychological safety; thus, the feedback conversations might be transformed [ 62 ].

Stable relationships enhance feedback dialogues, which offer an opportunity to co-construct learning and propose and negotiate aspects of the design of learning strategies [ 62 ].

Students as active agents in the feedback processes

The feedback response learners generate depends on the type of feedback information they receive, how credible the source of feedback information is, the relationship between the receiver and the giver, and the relevance of the information delivered [ 49 ]. Garino (2020) noted that students who are most successful in using feedback are those who do not take criticism personally, who understand what they need to improve and know they can do so, who value and feel meaning in criticism, are not surprised to receive it, and who are motivated to seek new feedback and use effective learning strategies [ 52 ]. Successful users of feedback ask others for help, are intentional about their learning, know what resources to use and when to use them, listen to and understand a message, value advice, and use effective learning strategies. They regulate their emotions, find meaning in the message, and are willing to change [ 52 ].

Student self-efficacy influences the understanding and use of feedback in the clinical workplace. McGinness et al. (2022) described various positive examples of self-efficacy regarding feedback processes: planning feedback meetings with teachers, fostering good relationships with the clinical team, demonstrating interest in assigned tasks, persisting in seeking feedback despite the patient workload, and taking advantage of opportunities for feedback, e.g., case presentations [ 67 ].

When students are encouraged to seek feedback aligned with their own learning objectives, they promote feedback information specific to what they want to learn and improve and enhance the use of feedback [ 53 ]. McGinness et al. (2022) identified that the perceived relevance of feedback information influenced the use of feedback because students were more likely to ask for feedback if they perceived that the information was useful to them. For example, if students feel part of the clinical team and participate in patient care, they are more likely to seek feedback [ 17 ].

Learning-oriented students aim to seek feedback to achieve clinical competence at the expected level [ 75 ]; they focus on improving their knowledge and skills and on professional development [ 17 ]. Performance-oriented students aim not to fail and to avoid negative feedback [ 17 , 75 ].

For effective feedback processes, including feed-up, feedback, and feedforward, the student must be feedback-oriented, i.e., active, seeking, listening to, interpreting, and acting on feedback [ 68 ]. The literature shows that feedback-oriented students are coproducers of learning [ 68 ] and are more involved in the feedback process [ 51 ]. Additionally, students who are metacognitively aware of their learning process are more likely to use feedback to reduce gaps in learning and performance [ 52 ]. For this, students must recognize feedback when it occurs and understand it when they receive it. Thus, it is important to organize training and promote feedback literacy so that students understand what feedback is, act on it, and improve the quality of feedback and their learning plans [ 68 ].

Table 5 summarizes those feedback tasks, activities, and key features of organizational aspects that enable each phase of the feedback loop based on the literature review.

The present scoping review identified 61 papers that mapped the literature on feedback processes in the WBL environments of undergraduate health professions. This review explored how feedback processes are organized in these learning contexts using the feedback loop framework. Given the specific characteristics of feedback processes in undergraduate clinical learning, three main findings were identified on how feedback processes are being conducted in the clinical environment and how these processes could be organized to support feedback processes.

First, the literature lacks a balance between the three dimensions of the feedback loop. In this regard, most of the articles in this review focused on reporting experiences or strategies for delivering feedback information (i.e., feedback dimension). Credible and objective feedback information is based on direct observation [ 46 ] and occurs within an interaction or a dialogue [ 62 , 88 ]. However, only having credible and objective information does not ensure that it will be considered, understood, used, and put into practice by the student [ 89 ].

Feedback-supporting actions aligned with goals and priorities facilitate effective feedback processes [ 89 ] because goal-oriented feedback focuses on students' learning needs [ 7 ]. In contrast, this review showed that only a minority of the studies highlighted the importance of aligning learning objectives and feedback (i.e., the feed-up dimension). To overcome this, supervisors and students must establish goals and agreements before starting clinical practice, as it allows students to measure themselves on a defined basis [ 90 , 91 ] and enhances students' feedback-seeking behavior [ 39 , 92 ] and responsiveness to feedback [ 83 ]. In addition, learning goals should be shared, and co-constructed, through a dialogue [ 50 , 88 , 90 , 92 ]. In fact, relationship-based feedback models emphasize setting shared goals and plans as part of the feedback process [ 68 ].

Many of the studies acknowledge the importance of establishing an action plan and promoting the use of feedback (i.e., feedforward). However, there is yet limited insight on how to best implement strategies that support the use of action plans, improve performance and close learning gaps. In this regard, it is described that delivering feedback without perceiving changes, results in no effect or impact on learning [ 88 ]. To determine if a feedback loop is closed, observing a change in the student's response is necessary. In other words, feedback does not work without repeating the same task [ 68 ], so teachers need to observe subsequent tasks to notice changes [ 88 ]. While feedforward is fundamental to long-term performance, it is shown that more research is needed to determine effective actions to be implemented in the WBL environment to close feedback loops.

Second, there is a need for more knowledge about designing feedback activities in the WBL environment that will generate constructive feedback for learning. WBA is the most frequently reported feedback activity in clinical workplace contexts [ 39 , 46 , 56 , 87 ]. Despite the efforts of some authors to use WBAs as a formative assessment and feedback opportunity, in several studies, a summative component of the WBA was presented as a barrier to actionable feedback [ 33 , 56 ]. Students suggest separating grading from observation and using, for example, the mini-CEX in informal situations [ 33 ]. Several authors also recommend disconnecting the summative components of WBAs to avoid generating emotions that can limit the uptake and use of feedback [ 28 , 93 ]. Other literature recommends purposefully designing a system of assessment using low-stakes data points for feedback and learning. Accordingly, programmatic assessment is a framework that combines both the learning and the decision-making function of assessment [ 94 , 95 ]. Programmatic assessment is a practical approach for implementing low-stakes as a continuum, giving opportunities to close the gap between current and desired performance and having the student as an active agent [ 96 ]. This approach enables the incorporation of low-stakes data points that target student learning [ 93 ] and provide performance-relevant information (i.e., meaningful feedback) based on direct observations during authentic professional activities [ 46 ]. Using low-stakes data points, learners make sense of information about their performance and use it to enhance the quality of their work or performance [ 96 , 97 , 98 ]. Implementing multiple instances of feedback is more effective than providing it once because it promotes closing feedback loops by giving the student opportunities to understand the feedback, make changes, and see if those changes were effective [ 89 ].

Third, the support provided by the teacher is fundamental and should be built into a reliable and long-term relationship, where the teacher must take the role of coach rather than assessor, and students should develop feedback agency and be active in seeking and using feedback to improve performance. Although it is recognized that institutional efforts over the past decades have focused on training teachers to deliver feedback, clinical supervisors' lack of teaching skills is still identified as a barrier to workplace feedback [ 99 ]. In particular, research indicates that clinical teachers lack the skills to transform the information obtained from an observation into constructive feedback [ 100 ]. Students are more likely to use feedback if they consider it credible and constructive [ 93 ] and based on stable relationships [ 93 , 99 , 101 ]. In trusting relationships, feedback can be straightforward and credible, and the likelihood of follow-up and actionable feedback improves [ 83 , 88 ]. Coaching strategies can be enhanced by teachers building an educational alliance that allows for trustworthy relationships or having supervisors with an exclusive coaching role [ 14 , 93 , 102 ].

Last, from a sociocultural perspective, individuals are the main actors in the learning process. Therefore, feedback impacts learning only if students engage and interact with it [ 11 ]. Thus, feedback design and student agency appear to be the main features of effective feedback processes. Accordingly, the present review identified that feedback design is a key feature for effective learning in complex environments such as WBL. Feedback in the workplace must ideally be organized and implemented to align learning outcomes, learning activities, and assessments, allowing learners to learn, practice, and close feedback loops [ 88 ]. To guide students toward performances that reflect long-term learning, an intensive formative learning phase is needed, in which multiple feedback processes are included that shape students´ further learning [ 103 ]. This design would promote student uptake of feedback for subsequent performance [ 1 ].

Strengths and limitations

The strengths of this study are (1) the use of an established framework, the Arksey and O'Malley's framework [ 22 ]. We included the step of socializing the results with stakeholders, which allowed the team to better understand the results from another perspective and offer a realistic look. (2) Using the feedback loop as a theoretical framework strengthened the results and gave a more thorough explanation of the literature regarding feedback processes in the WBL context. (3) our team was diverse and included researchers from different disciplines as well as a librarian.

The present scoping review has several limitations. Although we adhered to the recommended protocols and methodologies, some relevant papers may have been omitted. The research team decided to select original studies and reviews of the literature for the present scoping review. This caused some articles, such as guidelines, perspectives, and narrative papers, to be excluded from the current study.

One of the inclusion criteria was a focus on undergraduate students. However, some papers that incorporated undergraduate and postgraduate participants were included, as these supported the results of this review. Most articles involved medical students. Although the authors did not limit the search to medicine, maybe some articles involving students from other health disciplines needed to be included, considering the search in other databases or journals.

The results give insight in how feedback could be organized within the clinical workplace to promote feedback processes. On a small scale, i.e., in the feedback encounter between a supervisor and a learner, feedback should be organized to allow for follow-up feedback, thus working on required learning and performance goals. On a larger level, i.e., in the clerkship programme or a placement rotation, feedback should be organized through appropriate planning of subsequent tasks and activities.

More insight is needed in designing a closed loop feedback process, in which specific attention is needed in effective feedforward practices. The feedback that stimulates further action and learning requires a safe and trustful work and learning environment. Understanding the relationship between an individual and his or her environment is a challenge for determining the impact of feedback and must be further investigated within clinical WBL environments. Aligning the dimensions of feed-up, feedback and feedforward includes careful attention to teachers’ and students’ feedback literacy to assure that students can act on feedback in a constructive way. In this line, how to develop students' feedback agency within these learning environments needs further research.

Boud D, Molloy E. Rethinking models of feedback for learning: The challenge of design. Assess Eval High Educ. 2013;38:698–712.

Article   Google Scholar  

Henderson M, Ajjawi R, Boud D, Molloy E. Identifying feedback that has impact. In: The Impact of Feedback in Higher Education. Springer International Publishing: Cham; 2019. p. 15–34.

Chapter   Google Scholar  

Winstone N, Carless D. Designing effective feedback processes in higher education: A learning-focused approach. 1st ed. New York: Routledge; 2020.

Google Scholar  

Ajjawi R, Boud D. Assessment & Evaluation in Higher Education Researching feedback dialogue: an interactional analysis approach. 2015. https://doi.org/10.1080/02602938.2015.1102863 .

Carless D. Feedback loops and the longer-term: towards feedback spirals. Assess Eval High Educ. 2019;44:705–14.

Sadler DR. Formative assessment and the design of instructional systems. Instr Sci. 1989;18:119–44.

Hattie J, Timperley H. The Power of Feedback The Meaning of Feedback. Rev Educ Res. 2007;77:81–112.

Zarrinabadi N, Rezazadeh M. Why only feedback? Including feed up and feed forward improves nonlinguistic aspects of L2 writing. Language Teaching Research. 2023;27(3):575–92.

Fisher D, Frey N. Feed up, back, forward. Educ Leadersh. 2009;67:20–5.

Reimann A, Sadler I, Sambell K. What’s in a word? Practices associated with ‘feedforward’ in higher education. Assessment evaluation in higher education. 2019;44:1279–90.

Esterhazy R. Re-conceptualizing Feedback Through a Sociocultural Lens. In: Henderson M, Ajjawi R, Boud D, Molloy E, editors. The Impact of Feedback in Higher Education. Cham: Palgrave Macmillan; 2019. https://doi.org/10.1007/978-3-030-25112-3_5 .

Bransen D, Govaerts MJB, Sluijsmans DMA, Driessen EW. Beyond the self: The role of co-regulation in medical students’ self-regulated learning. Med Educ. 2020;54:234–41.

Ramani S, Könings KD, Ginsburg S, Van Der Vleuten CP. Feedback Redefined: Principles and Practice. J Gen Intern Med. 2019;34:744–53.

Atkinson A, Watling CJ, Brand PL. Feedback and coaching. Eur J Pediatr. 2022;181(2):441–6.

Suhoyo Y, Schonrock-Adema J, Emilia O, Kuks JBM, Cohen-Schotanus JA. Clinical workplace learning: perceived learning value of individual and group feedback in a collectivistic culture. BMC Med Educ. 2018;18:79.

Bowen L, Marshall M, Murdoch-Eaton D. Medical Student Perceptions of Feedback and Feedback Behaviors Within the Context of the “Educational Alliance.” Acad Med. 2017;92:1303–12.

Bok HGJ, Teunissen PW, Spruijt A, Fokkema JPI, van Beukelen P, Jaarsma DADC, et al. Clarifying students’ feedback-seeking behaviour in clinical clerkships. Med Educ. 2013;47:282–91.

Al-Kadri HM, Al-Kadi MT, Van Der Vleuten CPM. Workplace-based assessment and students’ approaches to learning: A qualitative inquiry. Med Teach. 2013;35(SUPPL):1.

Dennis AA, Foy MJ, Monrouxe LV, Rees CE. Exploring trainer and trainee emotional talk in narratives about workplace-based feedback processes. Adv Health Sci Educ. 2018;23:75–93.

Watling C, LaDonna KA, Lingard L, Voyer S, Hatala R. ‘Sometimes the work just needs to be done’: socio-cultural influences on direct observation in medical training. Med Educ. 2016;50:1054–64.

Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for Learners in Medical Education: What is Known? A Scoping Review Academic Medicine. 2017;92:1346–54.

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19–32.

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med. 2018;169:467–73.

Colquhoun HL, Levac D, O’brien KK, Straus S, Tricco AC, Perrier L, et al. Scoping reviews: time for clarity in definition methods and reporting. J Clin Epidemiol. 2014;67:1291–4.

StArt - State of Art through Systematic Review. 2013.

Levac D, Colquhoun H, O’Brien KK. Scoping studies: Advancing the methodology. Implementation Science. 2010;5:1–9.

Peters MDJ, BPharm CMGHK, Parker PMD, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13:141–6.

Bing-You R, Varaklis K, Hayes V, Trowbridge R, Kemp H, McKelvy D, et al. The Feedback Tango: An Integrative Review and Analysis of the Content of the Teacher-Learner Feedback Exchange. Acad Med. 2018;93:657–63.

Ossenberg C, Henderson A, Mitchell M. What attributes guide best practice for effective feedback? A scoping review. Adv Health Sci Educ. 2019;24:383–401.

Spooner M, Duane C, Uygur J, Smyth E, Marron B, Murphy PJ, et al. Self -regulatory learning theory as a lens on how undergraduate and postgraduate learners respond to feedback: A BEME scoping review: BEME Guide No. 66. Med Teach. 2022;44:3–18.

Long S, Rodriguez C, St-Onge C, Tellier PP, Torabi N, Young M. Factors affecting perceived credibility of assessment in medical education: A scoping review. Adv Health Sci Educ. 2022;27:229–62.

Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for Learners in Medical Education: What is Known? A Scoping Review: Lippincott Williams and Wilkins; 2017.

Schopper H, Rosenbaum M, Axelson R. “I wish someone watched me interview:” medical student insight into observation and feedback as a method for teaching communication skills during the clinical years. BMC Med Educ. 2016;16:286.

Crommelinck M, Anseel F. Understanding and encouraging feedback-seeking behaviour: a literature review. Med Educ. 2013;47:232–41.

Adamson E, Kinga L, Foy L, McLeodb M, Traynor J, Watson W, et al. Feedback in clinical practice: Enhancing the students’ experience through action research. Nurse Educ Pract. 2018;31:48–53.

Al-Mously N, Nabil NM, Al-Babtain SA, et al. Undergraduate medical students’ perceptions on the quality of feedback received during clinical rotations. Med Teach. 2014;36(Supplement 1):S17-23.

Bates J, Konkin J, Suddards C, Dobson S, Pratt D. Student perceptions of assessment and feedback in longitudinal integrated clerkships. Med Educ. 2013;47:362–74.

Bennett AJ, Goldenhar LM, Stanford K. Utilization of a Formative Evaluation Card in a Psychiatry Clerkship. Acad Psychiatry. 2006;30:319–24.

Bok HG, Jaarsma DA, Spruijt A, Van Beukelen P, Van Der Vleuten CP, Teunissen PW, et al. Feedback-giving behaviour in performance evaluations during clinical clerkships. Med Teach. 2016;38:88–95.

Bok HG, Teunissen PW, Spruijt A, Fokkema JP, van Beukelen P, Jaarsma DA, et al. Clarifying students’ feedback-seeking behaviour in clinical clerkships. Med Educ. 2013;47:282–91.

Calleja P, Harvey T, Fox A, Carmichael M, et al. Feedback and clinical practice improvement: A tool to assist workplace supervisors and students. Nurse Educ Pract. 2016;17:167–73.

Carey EG, Wu C, Hur ES, Hasday SJ, Rosculet NP, Kemp MT, et al. Evaluation of Feedback Systems for the Third-Year Surgical Clerkship. J Surg Educ. 2017;74:787–93.

Daelmans HE, Overmeer RM, Van der Hem-Stokroos HH, Scherpbier AJ, Stehouwer CD, van der Vleuten CP. In-training assessment: qualitative study of effects on supervision and feedback in an undergraduate clinical rotation. Medical education. 2006;40(1):51–8.

DeWitt D, Carline J, Paauw D, Pangaro L. Pilot study of a ’RIME’-based tool for giving feedback in a multi-specialty longitudinal clerkship. Med Educ. 2008;42:1205–9.

Dolan BM, O’Brien CL, Green MM. Including Entrustment Language in an Assessment Form May Improve Constructive Feedback for Student Clinical Skills. Med Sci Educ. 2017;27:461–4.

Duijn CC, Welink LS, Mandoki M, Ten Cate OT, Kremer WD, Bok HG. Am I ready for it? Students’ perceptions of meaningful feedback on entrustable professional activities. Perspectives on medical education. 2017;6:256–64.

Elnicki DM, Zalenski D. Integrating medical students’ goals, self-assessment and preceptor feedback in an ambulatory clerkship. Teach Learn Med. 2013;25:285–91.

Embo MP, Driessen EW, Valcke M, Van der Vleuten CP. Assessment and feedback to facilitate self-directed learning in clinical practice of Midwifery students. Medical teacher. 2010;32(7):e263-9.

Eva KW, Armson H, Holmboe E, Lockyer J, Loney E, Mann K, et al. Factors influencing responsiveness to feedback: On the interplay between fear, confidence, and reasoning processes. Adv Health Sci Educ. 2012;17:15–26.

Farrell L, Bourgeois-Law G, Ajjawi R, Regehr G. An autoethnographic exploration of the use of goal oriented feedback to enhance brief clinical teaching encounters. Adv Health Sci Educ. 2017;22:91–104.

Fernando N, Cleland J, McKenzie H, Cassar K. Identifying the factors that determine feedback given to undergraduate medical students following formative mini-CEX assessments. Med Educ. 2008;42:89–95.

Garino A. Ready, willing and able: a model to explain successful use of feedback. Adv Health Sci Educ. 2020;25:337–61.

Garner MS, Gusberg RJ, Kim AW. The positive effect of immediate feedback on medical student education during the surgical clerkship. J Surg Educ. 2014;71:391–7.

Bing-You R, Hayes V, Palka T, Ford M, Trowbridge R. The Art (and Artifice) of Seeking Feedback: Clerkship Students’ Approaches to Asking for Feedback. Acad Med. 2018;93:1218–26.

Haffling AC, Beckman A, Edgren G. Structured feedback to undergraduate medical students: 3 years’ experience of an assessment tool. Medical teacher. 2011;33(7):e349-57.

Harrison CJ, Könings KD, Dannefer EF, Schuwirth LWTT, Wass V, van der Vleuten CPMM. Factors influencing students’ receptivity to formative feedback emerging from different assessment cultures. Perspect Med Educ. 2016;5:276–84.

Harrison CJ, Könings KD, Schuwirth LW, Wass V, Van der Vleuten CP, Konings KD, et al. Changing the culture of assessment: the dominance of the summative assessment paradigm. BMC medical education. 2017;17:1–4.

Harvey P, Radomski N, O’Connor D. Written feedback and continuity of learning in a geographically distributed medical education program. Medical teacher. 2013;35(12):1009–13.

Hochberg M, Berman R, Ogilvie J, Yingling S, Lee S, Pusic M, et al. Midclerkship feedback in the surgical clerkship: the “Professionalism, Reporting, Interpreting, Managing, Educating, and Procedural Skills” application utilizing learner self-assessment. Am J Surg. 2017;213:212–6.

Holmboe ES, Yepes M, Williams F, Huot SJ. Feedback and the mini clinical evaluation exercise. Journal of general internal medicine. 2004;19(5):558–61.

Tai JHM, Canny BJ, Haines TP, Molloy EK. The role of peer-assisted learning in building evaluative judgement: opportunities in clinical medical education. Adv Health Sci Educ. 2016;21:659–76.

Johnson CE, Keating JL, Molloy EK. Psychological safety in feedback: What does it look like and how can educators work with learners to foster it? Med Educ. 2020;54:559–70.

Joshi A, Generalla J, Thompson B, Haidet P. Facilitating the Feedback Process on a Clinical Clerkship Using a Smartphone Application. Acad Psychiatry. 2017;41:651–5.

Kiger ME, Riley C, Stolfi A, Morrison S, Burke A, Lockspeiser T. Use of Individualized Learning Plans to Facilitate Feedback Among Medical Students. Teach Learn Med. 2020;32:399–409.

Kogan J, Shea J. Implementing feedback cards in core clerkships. Med Educ. 2008;42:1071–9.

Lefroy J, Walters B, Molyneux A, Smithson S. Can learning from workplace feedback be enhanced by reflective writing? A realist evaluation in UK undergraduate medical education. Educ Prim Care. 2021;32:326–35.

McGinness HT, Caldwell PHY, Gunasekera H, Scott KM. ‘Every Human Interaction Requires a Bit of Give and Take’: Medical Students’ Approaches to Pursuing Feedback in the Clinical Setting. Teach Learn Med. 2022. https://doi.org/10.1080/10401334.2022.2084401 .

Noble C, Billett S, Armit L, Collier L, Hilder J, Sly C, et al. ``It’s yours to take{’’}: generating learner feedback literacy in the workplace. Adv Health Sci Educ. 2020;25:55–74.

Ogburn T, Espey E. The R-I-M-E method for evaluation of medical students on an obstetrics and gynecology clerkship. Am J Obstet Gynecol. 2003;189:666–9.

Po O, Reznik M, Greenberg L. Improving a medical student feedback with a clinical encounter card. Ambul Pediatr. 2007;7:449–52.

Parkes J, Abercrombie S, McCarty T, Parkes J, Abercrombie S, McCarty T. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ. 2013;18:397–407.

Paukert JL, Richards ML, Olney C. An encounter card system for increasing feedback to students. Am J Surg. 2002;183:300–4.

Rassos J, Melvin LJ, Panisko D, Kulasegaram K, Kuper A. Unearthing Faculty and Trainee Perspectives of Feedback in Internal Medicine: the Oral Case Presentation as a Model. J Gen Intern Med. 2019;34:2107–13.

Rizan C, Elsey C, Lemon T, Grant A, Monrouxe L. Feedback in action within bedside teaching encounters: a video ethnographic study. Med Educ. 2014;48:902–20.

Robertson AC, Fowler LC. Medical student perceptions of learner-initiated feedback using a mobile web application. Journal of medical education and curricular development. 2017;4:2382120517746384.

Scheidt PC, Lazoritz S, Ebbeling WL, Figelman AR, Moessner HF, Singer JE. Evaluation of system providing feedback to students on videotaped patient encounters. J Med Educ. 1986;61(7):585–90.

Sokol-Hessner L, Shea J, Kogan J. The open-ended comment space for action plans on core clerkship students’ encounter cards: what gets written? Acad Med. 2010;85:S110–4.

Sox CM, Dell M, Phillipi CA, Cabral HJ, Vargas G, Lewin LO. Feedback on oral presentations during pediatric clerkships: a randomized controlled trial. Pediatrics. 2014;134:965–71.

Spickard A, Gigante J, Stein G, Denny JC. Automatic capture of student notes to augment mentor feedback and student performance on patient write-ups. J Gen Intern Med. 2008;23:979–84.

Suhoyo Y, Van Hell EA, Kerdijk W, Emilia O, Schönrock-Adema J, Kuks JB, et al. nfluence of feedback characteristics on perceived learning value of feedback in clerkships: does culture matter? BMC medical education. 2017;17:1–7.

Torre DM, Simpson D, Sebastian JL, Elnicki DM. Learning/feedback activities and high-quality teaching: perceptions of third-year medical students during an inpatient rotation. Acad Med. 2005;80:950–4.

Urquhart LM, Ker JS, Rees CE. Exploring the influence of context on feedback at medical school: a video-ethnography study. Adv Health Sci Educ. 2018;23:159–86.

Watling C, Driessen E, van der Vleuten C, Lingard L. Learning culture and feedback: an international study of medical athletes and musicians. Med Educ. 2014;48:713–23.

Watling C, Driessen E, van der Vleuten C, Vanstone M, Lingard L. Beyond individualism: Professional culture and its influence on feedback. Med Educ. 2013;47:585–94.

Soemantri D, Dodds A, Mccoll G. Examining the nature of feedback within the Mini Clinical Evaluation Exercise (Mini-CEX): an analysis of 1427 Mini-CEX assessment forms. GMS J Med Educ. 2018;35:Doc47.

Van De Ridder JMMM, Stokking KM, McGaghie WC, ten Cate OTJ, van der Ridder JM, Stokking KM, et al. What is feedback in clinical education? Med Educ. 2008;42:189–97.

van de Ridder JMMM, McGaghie WC, Stokking KM, ten Cate OTJJ. Variables that affect the process and outcome of feedback, relevant for medical training: a meta-review. Med Educ. 2015;49:658–73.

Boud D. Feedback: ensuring that it leads to enhanced learning. Clin Teach. 2015. https://doi.org/10.1111/tct.12345 .

Brehaut J, Colquhoun H, Eva K, Carrol K, Sales A, Michie S, et al. Practice feedback interventions: 15 suggestions for optimizing effectiveness. Ann Intern Med. 2016;164:435–41.

Ende J. Feedback in clinical medical education. J Am Med Assoc. 1983;250:777–81.

Cantillon P, Sargeant J. Giving feedback in clinical settings. Br Med J. 2008;337(7681):1292–4.

Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach. 2007;29:855–71.

Watling CJ, Ginsburg S. Assessment, feedback and the alchemy of learning. Med Educ. 2019;53:76–85.

van der Vleuten CPM, Schuwirth LWT, Driessen EW, Dijkstra J, Tigelaar D, Baartman LKJ, et al. A model for programmatic assessment fit for purpose. Med Teach. 2012;34:205–14.

Schuwirth LWT, der Vleuten CPM. Programmatic assessment: from assessment of learning to assessment for learning. Med Teach. 2011;33:478–85.

Schut S, Driessen E, van Tartwijk J, van der Vleuten C, Heeneman S. Stakes in the eye of the beholder: an international study of learners’ perceptions within programmatic assessment. Med Educ. 2018;52:654–63.

Henderson M, Boud D, Molloy E, Dawson P, Phillips M, Ryan T, Mahoney MP. Feedback for learning. Closing the assessment loop. Framework for effective learning. Canberra, Australia: Australian Government, Department for Education and Training; 2018.

Heeneman S, Pool AO, Schuwirth LWT, van der Vleuten CPM, Driessen EW, Oudkerk A, et al. The impact of programmatic assessment on student learning: theory versus practice. Med Educ. 2015;49:487–98.

Lefroy J, Watling C, Teunissen P, Brand P, Watling C. Guidelines: the do’s, don’ts and don’t knows of feedback for clinical education. Perspect Med Educ. 2015;4:284–99.

Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34:787–91.

Telio S, Ajjawi R, Regehr G. The, “Educational Alliance” as a Framework for Reconceptualizing Feedback in Medical Education. Acad Med. 2015;90:609–14.

Lockyer J, Armson H, Könings KD, Lee-Krueger RC, des Ordons AR, Ramani S, et al. In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context. J Grad Med Educ. 2020;12:27–35.

Black P, Wiliam D. Developing the theory of formative assessment. Educ Assess Eval Account. 2009;21:5–31.

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Depression and Anxiety Among Medical Students: A Brief Overview

Ahmad a mirza.

1 Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia

Mukhtiar Baig

2 Department of Clinical Biochemistry/Medical Education, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia

Ghada M Beyari

3 Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia

Mohammed Aiman Halawani

Abdulrahim a mirza.

4 Department of Surgery – Division of Urology, Ministry of National Guard - Health Affairs, Jeddah, Saudi Arabia

Depression and anxiety are highly prevalent conditions worldwide. This article reviews the extent of depression and anxiety among medical students and elucidates associated potential risk factors. In comparison to other countries, students from Middle East countries have a higher prevalence of depression. Females suffer from these conditions more commonly than males. Factors associated with these morbidities can be divided into academic and non-academic factors. There is an inconclusiveness of whether medical students experience these symptoms more commonly than their counterparts. The present review provided a cross-sectional picture of the students’ psychological well-being, which is crucial to formulate a health policy for preventive and therapeutic purposes.

Introduction

Globally, mental health among undergraudate students represents an important public health entity. University students face considerable demands in school and family, resulting in significant psychological stress that may lead to serious disorders and mental health issues such as depression and anxiety. As a result, university students’ academic performance, physical well-being and mental health may substantially worsen over the academic career and could only be detected at an advanced stage. Additionally, studies conducted among medical school graduates showed that psychological distress was associated with suboptimal quality of patient care, patient safety and professionalism. 1 , 2 The present review provides a cross-sectional picture of the current condition of the psychological well-being of medical students. In addition, it sheds light on significant predictors of depression and anxiety and helps to identify and manage major stressors in academic life.

For this narrative review, MEDLINE was searched for peer-reviewed publications in the English literature (publication period: from the inception untill 2018). We searched the grouping of Medical Subject Heading phrases: (medical students) AND (depression OR anxiety). Additional works was identified from these publications’ reference lists. Each paper was objectively reviewed and included, as applicable, based on the presentation of primary data, the quality of the methodology used, the clarity of the findings, and the dependence on the existing instruments to quantify depression and anxiety. Abundant literature is available on this topic; we included only a few important and informative research articles in this review. The ethical review committee’s approval for this report was not required, as it was a narrative review of previously published researches.

Prevalence of Depression

Depression represents a significant health problem in university populations, with about one-third of students are affected. 3 A systematic review estimated that the mean prevalence of depressive disorders in university students was 30.6%, which was considerably higher than rates reported in general populations. 3 Epidemiological data suggested that the prevalence of depression increased by 18.4% from 2005 to 2015. 4

Regional distribution showed a high frequency of depression in the Middle East with a prevalence of 31.8%, followed by North America with an incidence of 30.3%, Asia (30.1%), South America (26.8%), and Europe (20%). 5 The estimated frequency of depression or its manifestations in medical students around the world was 27.2%, according to a recent systematic review and meta-analysis. 6 Another systematic review found that the prevalence of depression varied between 6.0–66.5%. 7 An United Arab of Emirates (UAE) study examined depression and anxiety in medical students, doctors and members of the Medical College for Girls in Dubai. They found that 28.6% of medical undergraduates and 7.8% of medical staff had a high score for depression. 8 The overall frequency of depression or its symptoms among medical undergraduates ranged from 1.4% to 73.5%. 6 , 9

Difference in Gender

Regarding gender, several studies reported significant differences between males and females, whereas others did not find any significant difference. 10–15 Overall, female undergraduate students tended to have more depression than males. 16 A study conducted among university students from 23 countries found that the prevalence of depressive symptoms was 19% among male students and 22% among female students. 17 Similarly, when prevalence was stratified by gender, female medical students were found to have a higher prevalence of depression (31.5%) than males (24.2%). 5 Although females are more at risk, male students’ high rates cause a special issue since they are less willing to seek help. 3

Factors Associated with Depression

Many factors might increase students’ susceptibility to depression. These factors include changes in lifestyle, financial stressors, family relationship changes, and academic worries with post-graduation life. 3 Other possible risk factors that significantly increase the crude odds ratio (OR) of having major depressive disorder include female gender, younger age, lower-class years, living alone in a rented room, and financial difficulty. 18 Furthermore, a study highlighted some specific factors for each academic level. Notably, 1st year students reported “volume of work” and “absence of feedback” as major stressors, while 3rd year students were stressed by “fears about future capability” and “pedagogical inadequacies”. Sixth year students, on the other hand, expressed worries about “non-supportive climate” in addition to the stressors reported by the 1st and 3rd year students. 12 Other social factors were associated with a high rate of depression such as family economic status. Higher rates of depression were reported among university students from low-income families than those from high socioeconomic families. Moreover, those who lived in rural areas were likely to have a greater risk for depression than those living in urban areas. 19 Students with substance abuse, students having a family history of depression and anxiety, and those who had lost a close relative in the past year were more likely to be depressed and anxious. 20

Difference Between Medical and Non-Medical Students

Several studies evaluated the depression rate and compared medical and non-medical students. A British study compared the degree of depression in medical students with their non-medical peers and discovered that medical college students had a lower prevalence of depression generally than non-medical students. 21 In contrast, a meta-analysis indicated that the depression rate among medical students was not significantly different from non-medical students. 5 A Swedish study investigated the factors linked to depression and explored the frequency of depressive disorders at various academic levels among medical students. 12 The study demonstrated that medical students had a higher prevalence of depressive disorders compared to the general population.

The Variation Across the Academic Years

The incidence of depression was found to be varied across the academic years in medical school. First-year students had the highest prevalence of depression (33.5%), and the rates gradually decreased until year 5 (20.5%). 5 According to another study, the highest rate of depression was diagnosed in medical students of the second year. 8 A Pakistani study stated a high prevalence of depression among newly entered students (1st and 2nd year students) compared to senior students. 20 In contrast, in another study, the risk of depression was significantly higher in third-year students (39%) compared to first-year students (28.4%), besides an increased level of perceived stress among the same group. 22 A study evaluated depression, anxiety, and stress disorders among medical students and revealed that the depression levels among students at the entry of medical school were similar to the general public, then progressively worsened over the academic period. 23

Prevalence of Anxiety

The prevalence of anxiety among medical students has been reported from different regions and countries. According to a cross-sectional study carried out in Pakistan, a high prevalence of anxiety (47.7%) was found among medical students. A mild, moderate, and severe anxiety symptoms were present in 27.6%, 13.6% and 6.5% of the students, respectively. 24 In India, a study reported that 66.9% of medical undergraduates suffered from anxiety. 16 A systematic review included medical colleges across Europe and countries speaking English outside North America and found that the frequency of anxiety varied between 7.7–65.5%. 7 A Turkish study showed a high frequency of anxiety (47.1%) among medical undergraduates. 19 A high prevalence rate of anxiety was also reported among medical undergraduates in an Egyptian university (73%), and Nepal (41.1%); while relatively lower rates were reported in Brazil (37.2%) and Great Britain (31.2%). 25–28 In the Middle East region, a study showed 28.7% of medical students suffered from anxiety. 8 A Saudi study showed that the frequency of morbid anxiety was 34.9% among medical undergraduates. 29

A study carried out among medical students showed a significant gender difference with twice the rate of anxiety among females compared to males (40% versus 20%). 30 Another study in Brazil assessed and compared the frequency and severity of symptoms of anxiety among first- and sixth-year medical students. They found that females were more likely to suffer from anxiety than males. 31 In Saudi Arabia, a cross-sectional study showed a significantly higher rate of psychological morbidities, including anxiety, among premedical, 1st, 2nd and 3rd year female medical students (89.7%) than males (60%); however, no significant differences were found between gender in all other years. 32

Factors Associated with Anxiety

Several risk factors that predispose undergraduate medical students to psychological disorders, like anxiety, have been reported. A study in Pakistan described that drugs addicted students, students with a positive family history of depression and anxiety, and individuals who had lost a close relative in the past year were more prone to suffer from psychological disorders and being anxious than other individuals. 20 Another study demonstrated that students with economic difficulties were at a higher risk for such disorders. 33 In Egypt, a study estimated the frequency of depression, anxiety and stress symptoms among undergraduates in a medical college and demonstrated the relationship of such conditions with sociodemographic data. They showed that the female gender, university campus residents, pre-clinical years students, and students with lower academic accomplishment had higher scores of anxiety than other groups. 25 Other issues may cause a significant effect on medical students’ mental and emotional well-being and induce anxiety such as long working and study hours, mastering medical knowledge, competition, and inadequate time for non-academic activities. 34 , 35 Additionally, anxiety was found to be positively predicted by a family history of mental disorders. 30 A study highlighted students’ three top concerns: academic performance, the pressure to succeed, and post-graduation plans. 36 Further studies are required to determine the factors linked with mental problems such as anxiety that influence medical undergraduates’ academic achievements.

A study in Portugal reported that anxiety symptoms were significantly more prevalent among medical students than non-medical students. 37 A systematic review that included students from the USA and Canada found greater anxiety levels among medical students than the general population. 38 Similarly, a comparative study conducted among female students in Dammam University, Saudi Arabia revealed a decrease in well-being and higher levels of anxiety among medical compared to non-medical students as early as the start of the bachelor’s program. 39

Many studies compared the levels of anxiety among different academic years in medical school; one found fluctuating rates of psychological disorders, including anxiety, among students, namely 45.86% in 1st, 52.58% in 2nd, 47.14% in 3rd, 28.75% in 4th, and 45.10% in final year. 40 Besides, anxiety symptoms were found to be frequent among medical students of 2nd year (61.6%). 24 Similarly, a Brazilian study reported a higher frequency of anxiety symptoms among 1st year medical students (30.8%) than in 6th year students (9.4%). 31

Significance of the Findings and Recommendations

The present narrative review showed that the prevalence of depression and anxiety is very high. The incidence of depression ranged from 1.4% to 73.5%, and the anxiety ranged from 7.7% to 65.5% among medical students. Female medical students were more vulnerable to anxiety and depression than male students. The associated factors with depression and anxiety are female gender, economic condition, academic pressure, etc. Furthermore, the rate of depression and anxiety among medical students fluctuates across the academic years. This probably due to the difference in academia and student life from one school to another. Future research to estimate the global burden of these psychological morbidities in both developing and developed countries is of vital importance. Depression and anxiety cause hindrance to medical students’ academic career and later to their social life. It is suggested that these factors should be considered among medical students, and students should be provided psychological counseling in their early academic years. Students’ support unit should help them in alleviating their associated factors that may jeopardize their bright career.

The present paper lacks a systematic comprehensive approach that is mandated in evidence synthesis. However, the goal was to provide a brief overview of the burden and potential risk factors of psychological impairments among medical students emphasizing the importance of synthesizing a higher level of evidence.

Acknowledgments

The authors gratefully acknowledge the invaluable guidance from Prof. Waleed Milaat and Prof. Iman Ramadan, professors in the Department of Community Medicine at King Abdulaziz University, Jeddah, Saudi Arabia. This article is a part of thesis submitted for the requirements of Master of Science degree in public health conferred by Department of Community Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.

Data Sharing Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

The authors declare that they have no competing interests.